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The first models of postnatal care were established at the start of the twentieth century, in response to high maternal mortality rates. Despite a dramatic reduction in the mortality rates since then, there has been little alteration in the timing or the content of care [1]. It is estimated that up to 47% of women have reported at least one health problem within the first six weeks of giving birth [2] and as many as 76% of women have at least one health problem within two months of giving birth [3]. The puerperium is usually taken to describe the six weeks in which a woman’s anatomy and physiology return to their pre-pregnancy states following childbirth. There is no specific definition for the immediate puerperium, but here it is taken to address the issues a woman may face in at least the first two weeks following delivery.
One of the challenges in postnatal care is that it crosses both the acute and primary healthcare sectors. A solution is to ensure that there is a system in place to provide women and their babies with an individualized postnatal care plan, which is reviewed and documented at each postnatal contact [4]. This should include relevant factors from the antenatal, intrapartum and immediate postnatal period. There should be details of a named midwife or health visitor, including a 24-hour telephone number to enable the woman to contact her named healthcare practitioner or an alternative practitioner should he or she not be available.
Specific plans for the postnatal period include managing medically related conditions when they occur, such as hypertension, thromboembolism, blood loss, infection, urinary tract- and bowel-related symptoms, postnatal wound care, pain, fatigue and mental health conditions. Other details such as adjustment to motherhood, emotional well-being and family support structures should be covered. Plans for feeding, including specific advice about either breastfeeding support or formula feeding, need to be included, as well as plans for contraceptive care [4]. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English [5].
The Postnatal Check
Women should be advised, within 24 hours of the birth, of the symptoms and signs of conditions that may threaten their lives and require them to access emergency treatment. Table 27.1 summarizes the signs and symptoms that are suggestive of potentially life-threatening physical and mental health conditions in the woman [4].
| Physical signs | Mental health signs |
|---|---|
| Sudden and profuse blood loss or persistent, increased blood loss | Severe depression, such as feeling extreme unnecessary worry |
| Faintness, dizziness, palpitations or tachycardia | Being unable to concentrate due to distraction from depressive feelings |
| Fever, shivering, abdominal pain, especially if combined with offensive vaginal loss or a slow- healing perineal wound | Severe anxiety, such as uncontrollable feelings of panic |
| Headaches accompanied by visual disturbances or nausea or vomiting within 72 hours of birth | Being unable to cope or becoming obsessive |
| Leg pain, associated with redness or swelling | The desire to hurt others or oneself |
| Shortness of breath or chest pain | Thoughts about taking one’s own life |
| Widespread rash | Confused and disturbed thoughts, including hallucinations and delusions |
Maternal Observations
The importance of routine measurements such as pulse, temperature, respiratory rate and blood pressure in any ill postnatal women cannot be over-emphasized. The results should be documented and acted upon; normality cannot be presumed without measurement [5]. The uterus should be examined and any deviation from normal noted. In addition, attention should be paid to the amount and nature of lochia passed, any caesarean section (CS) scars or perineal trauma, bladder and bowel function, as well as thrombosis risk.
Infant Care
Women should also be warned about a major change in the baby’s behaviour, as highlighted in Table 27.2 [4].
| Less active/responsive than usual, or more irritable than usual. | |
| Breathing faster than usual or grunting when breathing. | |
| Feeding less than usual or nappies much less wet than usual. | |
| Has blue lips or, with the exception of hands and feet, feels cold when dressed appropriately for the environment temperature. | |
| Has a fit or is floppy. | |
| Vomits green fluid or has blood in their stools. | |
| Has a rash that does not fade when pressed with a glass or has a temperature higher than 38 °C. | |
| Has a bulging or very depressed fontanelle. | |
| Within the first 24 hours after the birth, has not passed urine, faeces (meconium) or develops a yellow skin colour (jaundice). |
There are specific behaviours that increase a baby’s risk of sudden infant death syndrome. Providing the woman, her partner or the main carer with the opportunity to regularly discuss infant sleeping practices can help to identify and support them and the wider family to establish safer infant sleeping habits, and to reduce the baby’s risk of sudden infant death syndrome [4].
Infant Feeding
Women should receive breastfeeding support through an integrated service that uses an evaluated, structured programme [4]. Babies who are fully or partially formula fed can develop infections and illnesses if their formula milk is not prepared safely. In a small number of babies these cause serious harm which may be life threatening, and require the baby to be admitted to hospital. The mother or main carer of the baby needs consistent, evidence-based advice about how to sterilize feeding equipment and safely prepare formula milk.
The baby’s relationship with the mother has a significant impact on the baby’s social and emotional development. In turn, the woman’s ability to provide a nurturing relationship is partly dependent on her own emotional well-being. Regular assessment of the woman’s emotional well-being and the impact of this on her attachment to her baby may lead to earlier detection of problems.
Mental State
Women experience emotional changes in the immediate postnatal period, which usually resolves within 10–14 days after the birth. Women who are still feeling low in mood, anxious, experiencing negative thoughts or lacking interest in their baby at 10–14 days after the birth may be at increased risk of mental health problems. These women should receive an assessment of their mental well-being [4].
General Health
The woman’s eating habits and physical activity levels could influence the health behaviour of the wider family, including children who are developing habits that may remain with them for life [4]. Supporting the woman in the postnatal period to change her eating habits and physical activity levels may improve her health, her infant’s health and the health of the wider family. It may also improve the outcomes of future pregnancies.
Advice on healthy eating and physical exercise (advising them to take a brisk walk or other moderate exercise for at least 30 min at least five days of the week) should be tailored to each individual woman [4]. Ongoing support over a sufficient period of time will allow for sustained lifestyle changes.
All non-sensitized Rhesus negative women should be offered an appropriate dose of anti-D immunoglobulin within 72 hours of delivery of a Rhesus positive baby. This should be based on the postdelivery Kleihauer Betke test. Similarly, the MMR (measles, mumps, rubella) vaccine should be offered to any woman found to be seronegative on antenatal screening for rubella. She should be advised not to get pregnant in the next three months.
Puerperal Complications
Postpartum Haemorrhage
Figures from the latest Confidential Enquiry into Maternal Deaths in the UK estimate that 13% of all maternities in England in 2011–12 were affected by a blood loss ≥500 ml. These figures have doubled since 2005 [5]. There are a number of preventive measures to reduce the complications caused by a postpartum haemorrhage. In the antenatal period, low haemoglobin levels should be investigated and optimized prior to delivery.
Physiological observations including the respiratory rate recorded within a trigger system such as the Modified Early Obstetric Warning Score (MEOWS) chart should be used to monitor all postnatal admissions. Concerns should be escalated to a senior doctor or midwife if a woman’s health deteriorates, and there should be a named senior doctor in charge of ongoing care [5]. Fluid resuscitation and blood transfusion should not be delayed because of false reassurance from a single haemoglobin result; the whole clinical picture should be considered.
While significant haemorrhage may be apparent from observed physiological disturbances, young, fit, pregnant women compensate remarkably well. While a tachycardia commonly develops, there can be a paradoxical bradycardia, and hypotension is always a very late sign; therefore, ongoing bleeding should be acted on without delay [5].
In a woman who is bleeding and is likely to develop a coagulopathy or has evidence of a coagulopathy, it is prudent to give blood components before coagulation indices deteriorate and worsen the bleeding. If pharmacological measures fail to control the haemorrhage, initiate surgical haemostasis sooner rather than later. Early recourse to hysterectomy is recommended if simpler medical and surgical interventions prove ineffective [5].
Postpartum Haematomas
Postpartum haematomas can present as vulval, paravaginal, intra-ligamentous (broad ligament) and retroperitoneal. Vulval haematomas can be further subdivided into perineal, ischiorectal and labial [6]. Vulvovaginal haematomas are an uncommon complication postpartum and the incidence can vary from 1 in 500 to 1 in over 12 000 [6].
In most cases, normal rather than abnormal labour and delivery are associated with their occurrence. Factors such as primiparity, a fetus over 4 kg, delayed second stage of labour, instrumental deliveries, episiotomies and genital tract varicosities are poor predictors of vulval haematomas [6].
Paravaginal haematomas can occur with trauma to the pudendal vessels because of their arterial component and lack of counter pressure; expansion within the vaginal, subvaginal and retroperitoneal tissues of the pelvis can occur. Vulval veins have no valves and therefore continued bleeding from trauma can cause gross distention of the soft tissues of the vagina and vulva [6].
The aim of surgical management is to alleviate the pain caused by the haematoma, prevent further bleeding and damage to tissue as well as to reduce the risk of subsequent infection. The clots should be evacuated to start with and if any bleeding vessels are identified, they should be clamped and ligated. Some authors have advised that the haematoma cavity be tightly packed with gauze and drained, with subsequent removal of the packs and healing by secondary intention [6]. Others advocate draining of the haematoma and primary repair. Angiographic embolization of the bleeding internal iliac artery tributaries and internal iliac artery ligation may be required in more severe cases [6].
What is crucial in the management of such cases is early recourse to treatment, as prolonged delay may result in increased pain and discomfort for the patient as well as further bleeding, tissue distortion, damage and necrosis. On diagnosing a vulvovaginal haematoma, aggressive fluid replacement, blood transfusion, antibiotics, indwelling urinary catheter and surgery are mandatory unless the haematoma is small, self-limiting and presents with minimal symptoms. In other cases, prompt treatment will result in reduced scarring, postpartum pain and dyspareunia.
Sepsis
Pregnant women are uniquely at risk from sepsis. Their immune system is modulated to accept foreign proteins from the feto-placental unit and usually they are young and fit, and able to withstand the physiological insults of widespread inflammation for long periods of time. Pregnant or postpartum women can appear well until the point of collapse, which can occur with little warning. However, more often than not a woman’s physiological vital signs, the pulse, blood pressure, temperature and respiratory rate, will give an indication of the early stages of sepsis [5]. In the majority of cases, the organism group A Streptococcus (GAS) is responsible for women who die from genital tract sepsis following term births. Most are following vaginal deliveries; in the few that are CS, this occurred despite the administration of antibiotics [5].
‘Severe sepsis’ is sepsis associated with organ dysfunction, for example acute renal failure or hypotension. ‘Septic shock’ is a vasodilatory form of shock and is defined as persisting hypotension despite adequate fluid resuscitation in the presence of sepsis [5]. Lactic acid is an important marker of tissue hypoxia and a strong indicator of the potential for multi-organ failure and mortality. A serum lactate measurement of >2 mmol/l indicates severe sepsis and >4 mmol/l indicates septic shock [5].
Antibiotic administration is crucial to the immediate management. From the recognition of signs of septic shock, each hour’s delay in administering antibiotic therapy increases the chance of mortality by 8% [5]. The choice of antibiotic is as important as timely administration. In most women with sepsis, antibiotics will be started prior to culture of the infecting organism. Antibiotic choice should therefore be based on the suspected site of infection, with the antibiotics chosen to have an appropriate spectrum of activity based on local prescribing guidelines. If the source of sepsis is unknown then antibiotics covering a broad range of possible organisms should be used and later the spectrum can be narrowed or targeted based on the culture results, radiological imaging or the development of specific signs or symptoms [5].
A woman with sepsis must receive the level of care she needs and critical care should be provided on the delivery unit if this is the most appropriate setting. Alternatively, maternity care should be provided on the critical care unit if this is the most appropriate setting [5].
Influenza A and B are highly infectious acute viral infections of the respiratory tract and should also be considered as a source of maternal sepsis. It usually occurs in a seasonal pattern, with epidemics in the winter months. Vaccination is the main public health response to influenza in general. Influenza vaccination in pregnancy reduces maternal morbidity and mortality, reduces the likelihood of perinatal death, prematurity and low birth weight and prevents influenza in the infant up to six months of age through transfer of maternal antibodies [5].
Ogilvie’s Syndrome
Ogilvie’s syndrome can occur after CS and result in caecal perforation. This is an extremely rare phenomenon following normal vaginal delivery, especially the progression to caecal perforation [7]. The exact aetiology of Ogilvie’s syndrome is unknown, but it has been associated with severe trauma, abdominal and/or pelvic surgery, and sepsis. Bed rest and abnormal electrolytes are listed as factors associated with the development of the syndrome. The mechanism of the condition is thought to involve loss of tone in the parasympathetic nerves S2 to S4. This, in turn, results in an atonic distal colon and pseudo obstruction [7].
A cut-off sign relating to an area of dilated and collapsed bowel around the splenic flexure corresponds to the transition zone between the vagal and sacral parasympathetic nerve supply. The cut-off sign is used to support the hypothesis of parasympathetic inhibition causing Ogilvie’s syndrome [7]. The diagnosis of Ogilvie’s syndrome can be difficult due to the non-specific clinical features. Abdominal distension is considered to be the most common symptom. As with any case of suspected ileus or obstruction, electrolyte levels are an essential investigation, with hypocalcaemia being the most common [7]. Abdominal radiography is the standard first line investigation, and a caecal diameter of 9 cm or more is the only definitive sign of imminent perforation [7]. Several sources have discussed non-surgical management options, which include decompression of the bowel and intravenous fluid support, unless signs of peritonism are evident. The use of prokinetic, parasympathomimetic drugs such as neostigmine can be successful in the management of Ogilvie’s syndrome, although the benefit in cases of idiopathic Ogilvie’s syndrome is not certain [7]. The importance of early diagnosis cannot be underestimated.
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